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Synapse TeamOct 21
How low should systolic pressure go after a stroke? If OPTIMAL-Stroke favours intensive control, what target would you aim for in clinic — and how would you handle the falls and orthostasis risk in older patients?
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Intensive Blood-Pressure Control in Patients with Previous Ischemic Stroke
Gisele SampaioGisele Sampaio SilvaM. Julia Machline-CarrionKarla SantoJoão Brainer Clares de AndradeEduardo Bello MartinsPatrícia O. GuimarãesFrederico MonfardiniJosué NieriSilvia Regina Lamas AssisSheila Cristina Ouriques MartinsOctávio Marques Pontes NetoAudes D. M. FeitosaCarla Heloísa Cabral MoroSandra Cristina Pereira Costa FuchsRubens José GagliardiOdílson Marcos SilvestreRicardo Pereira SilvaMurillo de Oliveira AntunesEva RochaCésar MinelliLília Nigro MaiaLuiz Aparecido BortolottoMarcio Gonçalves SousaLuciano F. DragerRodrigo BazánJosé Fernando Vilela-MartinJamary Oliveira‐FilhoViviane Flumignan ZétolaWagner AvelarLeonardo Augusto CarboneraGabriel Pereira BragaAdriana Bastos ConfortoCaio A.M. TavaresFabrício Oliveira LimaGladys Lentz MartinsLetícia Costa RebelloAnthony RodgersPaul K. WheltonFlávio Danni FuchsOtávio Berwanger
What happened
Intensive blood-pressure control cuts major cardiovascular events ~21% vs standard control after stroke or TIA.
- HR 0.79
- 95% CI 0.67-0.94
- P=0.007
- n=4,368
Key points
- Context & question: The OPTIMAL-Stroke trial was conducted because it remained uncertain whether intensive blood-pressure control reduces cardiovascular risk following a cerebrovascular event. It aimed to compare an intensive systolic blood pressure target of less than 120 mm Hg with a standard target of less than 140 mm Hg in patients with a history of ischemic stroke or transient ischemic attack.
- Methods & population: Study design, patient population, and sample size are not yet reported.
- Finding & limits: Intensive blood pressure control (<120 mm Hg) reduced the primary composite outcome of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina or heart failure compared to standard control (<140 mm Hg) (10.9% vs. 13.5%; HR 0.79, 95% CI 0.67-0.94; p=0.007). How much the drop in kidney function matters long term is still open. The investigators point to no increase in end-stage renal disease, dialysis, or renal mortality. Commenters also call for individualized targets, which leaves open which stroke patients should get the lower goal.
Discussion
Expert perspectives 10
Robert Avram
Practice takeInterventional / Structural Cardiology · Montreal Heart Institute
Lower blood pressure after stroke brings benefit with a kidney trade-off, so think beyond the number.
Read full perspective
Avram notes the targets of <120 vs <140 cut CV events (10.9% vs 13.5%, HR 0.79), but renal events rose (3.9% vs 2.2%). His takeaway is to think beyond the BP number.
Expert perspective
Otavio Berwanger16h ago
General Cardiology
Controlling blood pressure after a stroke is especially important because it can help prevent another stroke, prevent other cardiovascular complications and protect patients’ lives.
OPTIMAL-Stroke co-authorExpert perspective
Otavio Berwanger16h ago
General Cardiology
This was primarily driven by a sustained drop in renal function; potentially a hemodynamic effect. We can discuss this further because there were no increase in the risk of end-stage renal disease. There was no increase in dialysis and no increase in renal mortality.
OPTIMAL-Stroke co-authorShow 7 more perspectivesShow fewer perspectives
Expert perspective
Dr Sharath Kumar G7h ago
OPTIMAL-STROKE: SBP target <120 vs <140 after ischemic stroke/TIA reduced the primary CV composite by 21% (ARR 2.6%; NNT ≈39 over 4 years). Benefit came with more renal events. Individualize targets & monitor kidneys. Long-term prevention—not acute stroke care. #Stroke
t.coOPTIMAL-StrokeExpert perspective
#LBS OPTIMAL-Stroke Trial conducted over 30 sites in Brazil compared targeting systolic #BP <120 to standard care <140 in pts with prior #stroke Congratulations @OtavioBerwanger & all investigators for this initiative & including > 45% women in both groups! 💎 primary outcome
t.coOPTIMAL-StrokeExpert perspective
Gisele Sampaio Silva16h ago
Universidade de São Paulo
Elevated blood pressure is the most important risk factor for recurrent stroke. Almost all patients after stroke leave on antihypertensive therapy, but what we don’t know is how low should we go. The SPRINT trial actually set the stage for the use of lower blood pressure thresholds with a goal of less than 120 mm Hg in patients with high cardiovascular risk factors, but this trial actually excluded patients with previous strokes, and other prophylaxis trials were either underpowered or were performed in a specific and limited stroke population.
OPTIMAL-StrokeExpert perspective
Martha Gulati14h ago
🧠 OPTIMAL-Stroke: 4,368 prior ischemic stroke/TIA; 47.9% women, followed for 3.9y 🫀lower 🆚 higher BP: SBP <120 vs <140: MACE 10.9% vs 13.5%; HR 0.79 (95% CI 0.67–0.94) 💥Supports lower target BP #AHA26 #ScientificSessions26 #CVPrev @NEJM
t.cot.coOPTIMAL-StrokeExpert perspective
Gisele Sampaio Silva16h ago
Universidade de São Paulo
Our study shows that for many people who have already experienced an ischemic stroke or TIA, aiming for a systolic blood pressure below 120 mm Hg can provide additional cardiovascular protection compared with the conventional target of below 140 mm Hg. However, we emphasize that achieving lower blood pressure safely requires appropriate medical supervision and additional monitoring, particularly of kidney function.
OPTIMAL-StrokeExpert perspective
Martha Gulati1d ago
OPTIMAL-STROKE 🧠❤️ Protect the brain. Protect the heart OPTIMAL-Stroke asks: Does intensive BP control prevent major CV events after stroke? Intensive treatment: SBP <120 mmHg 🆚 Standard treatment: SBP <140 mmHg 🔎 I’ll be watching: ✅ Absolute benefit ✅ Safety ✅ Who
OPTIMAL-StrokeExpert perspective
Preparing for @ahascience.bsky.social #ScientificSessions26 & so many #LBS sessions! Looking fwd to the findings from The OPTIMAL-Stroke Trial as well as Attain-OSA & so many more So pleased to see dedicated "Women’s Focused Programming"❤️rather than "Special Populations" banner #gratitude
OPTIMAL-StrokeOutstanding questions
Open questions from this trial that would benefit from expert input.
Ask about this paper
Answers are grounded in this paper and cite their sources.
Full evidence
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Full evidence
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Why the trial?
The OPTIMAL-Stroke trial was conducted because it remained uncertain whether intensive blood-pressure control reduces cardiovascular risk following a cerebrovascular event. It aimed to compare an intensive systolic blood pressure target of less than 120 mm Hg with a standard target of less than 140 mm Hg in patients with a history of ischemic stroke or transient ischemic attack.
Does intensive blood-pressure control targeting a systolic blood pressure <120 mm Hg reduce major cardiovascular events compared with standard treatment targeting <140 mm Hg in patients with elevated blood pressure and previous ischemic stroke or transient ischemic attack?
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Key Points
- To assess whether intensive systolic blood-pressure control reduces major adverse cardiovascular events compared with standard control in patients with prior ischemic stroke or transient ischemic attack.
- Open-label, multicenter randomized trial conducted across 30 sites in Brazil involving 4368 participants with elevated blood pressure and prior ischemic stroke or transient ischemic attack (OPTIMAL-STROKE; NCT04036409).
- Participants were randomly assigned to intensive blood-pressure lowering targeting systolic pressure under 120 mm Hg (n=2172) or standard treatment targeting under 140 mm Hg (n=2196), with a median follow-up of 3.9 years.
- Mean systolic blood pressure achieved during follow-up (excluding the first 3 months) was 122.0±11.5 mm Hg in the intensive group versus 135.2±9.7 mm Hg in the standard group (between-group difference, 13.1 mm Hg; 95% CI, 12.5 to 13.8).
- The primary composite outcome occurred in 236 participants (10.9%; 3.25 per 100 person-years) in the intensive group compared with 297 participants (13.5%; 4.11 per 100 person-years) in the standard group (hazard ratio, 0.79; 95% CI, 0.67 to 0.94; P=0.007).
- The composite renal outcome of sustained reduction of at least 50% in estimated glomerular filtration rate or progression to end-stage renal disease occurred more frequently with intensive treatment, while serious adverse events were similar between groups.
Structured PICO
Does intensive blood-pressure control targeting a systolic blood pressure <120 mm Hg reduce major cardiovascular events compared with standard treatment targeting <140 mm Hg in patients with elevated blood pressure and previous ischemic stroke or transient ischemic attack?
Population
4,368 adults in Brazil (mean age 63.9 years, 47.9% women) with elevated blood pressure and previous ischemic stroke or transient ischemic attack, followed for a median of 3.9 years.
Intervention
Intensive blood-pressure treatment targeting a systolic blood pressure of less than 120 mm Hg over a median follow-up of 3.9 years (n=2,172).
Comparator
Standard blood-pressure treatment targeting a systolic blood pressure of less than 140 mm Hg over a median follow-up of 3.9 years (n=2,196).
Outcome
Composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina or heart failure over a median follow-up of 3.9 years.composite endpoint
Main Result
Hazard Ratio0.79 (95% CI 0.67–0.94)
Absolute Event Rate10.9% vs 13.5%
p-valuep=0.007
In patients with prior ischemic stroke or TIA, intensive blood-pressure lowering to a systolic target <120 mm Hg significantly reduced major cardiovascular events compared with a standard target <140 mm Hg, though with a higher incidence of adverse renal outcomes.
Limitations
- Open-label design
Where experts stand
Hypertension management evidence still formingExperts read OPTIMAL-Stroke as support for a lower blood pressure target after ischemic stroke or TIA, but they add that kidney function needs closer watching.
Clinicians and investigators agree that aiming lower after a prior ischemic stroke or TIA prevented more major cardiovascular events than the usual target. The shared caveat is a rise in kidney-related events with intensive treatment, so most frame this as a benefit that requires supervision and monitoring. The live question is whether that kidney signal is a harmless blood flow effect or a real cost that should limit who gets the lower target.
Agreement
Several clinicians independently say the cardiovascular benefit of the lower target came with more kidney events, and that kidney function should be monitored when treating to it.
2 clinicians say this directly
3 takes classified by contention axis so far — the map appears as more land.
Still unclear
How much the drop in kidney function matters long term is still open. The investigators point to no increase in end-stage renal disease, dialysis, or renal mortality. Commenters also call for individualized targets, which leaves open which stroke patients should get the lower goal.
Implication
Results of OPTIMAL-Stroke are pending; leaves open optimal BP targets for secondary stroke prevention.
Abstract
Background Whether intensive blood-pressure control reduces cardiovascular risk after cerebrovascular events remains uncertain. Methods In this multicenter, open-label, randomized trial conducted at 30 sites in Brazil, we assigned participants with elevated blood pressure and previous ischemic stroke or transient ischemic attack to receive intensive treatment targeting a systolic blood pressure of less than 120 mm Hg or to receive standard treatment targeting a systolic blood pressure of less than 140 mm Hg. The primary outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina or heart failure. Results A total of 4368 participants were enrolled, with 2172 assigned to intensive treatment and 2196 to standard treatment. The mean (±SD) age of the participants was 63.9±11.2 years, and 2093 (47.9%) were women. During the follow-up period, excluding the first 3 months, the mean systolic blood pressure was 122.0±11.5 mm Hg (median, 119.6 mm Hg) in the intensive-treatment group and 135.2±9.7 mm Hg (median, 135.0 mm Hg) in the standard-treatment group, with a between-group mean difference of 13.1 mm Hg (95% confidence interval [CI], 12.5 to 13.8). Over a median follow-up of 3.9 years, a primary-outcome event occurred in 236 participants (10.9%; 3.25 events per 100 person-years) with intensive treatment and in 297 (13.5%; 4.11 events per 100 person-years) with standard treatment (hazard ratio, 0.79; 95% CI, 0.67 to 0.94; P=0.007). The composite renal outcome (sustained reduction of ≥50% in the estimated glomerular filtration rate or progression to end-stage renal disease) was more common with intensive treatment. The overall incidence of serious adverse events was similar in the two groups. Conclusions Among participants with previous ischemic stroke or transient ischemic attack, targeting a systolic blood pressure of less than 120 mm Hg resulted in a lower incidence of major cardiovascular events than targeting a systolic blood pressure of less than 140 mm Hg. (Funded by Hospital Israelita Albert Einstein and the Brazilian Ministry of Health; OPTIMAL-STROKE ClinicalTrials.gov number, NCT04036409.)
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Silva et al. (2026) conducted an RCT in Elevated blood pressure and previous ischemic stroke or transient ischemic attack (n=4,368). Intensive blood-pressure treatment (target SBP <120 mm Hg) vs. Standard treatment targeting a systolic blood pressure of <140 mm Hg was evaluated on Composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina or heart failure (HR 0.79, 95% CI 0.67-0.94, p=0.007). Intensive blood-pressure control (target SBP <120 mm Hg) reduced major cardiovascular events compared with standard treatment (<140 mm Hg) after stroke/TIA (10.9% vs 13.5%; HR 0.79; 95% CI 0.67-0.94; P=0.007).